HomeMy WebLinkAbout2627 Thoreau Dr - Special Inspections/Backflow - 06/15/2007JUN-19-2007 TUE 02:42 PM
FORT.COLLINS UTILITIES
9704162442
P. 06
BACKFLOW DEVICE
TEST REPORT
913's Bac? w fisting LLC
"Ym.r CnusL'nvuenus Corvucetwt"
1540 27th St., Grceley, CO 80631 - (970) 352-3090 or (303) 981-7032 Cell
WTR Dist. plc. 1•< _
Meocr>
No.
5233
Owner e 3
Service Address ��./i �% `fi...,r�,oC, Q s7&US7 005,-b:�
Mailing Address for tP 4 -? 4 -7 4 G
Con'act— S._._+ Title:Sp1�/ Phone:
RP ❑ DC ❑ PVB 16, CONTAINME-NT ❑ ISOLATION ❑. DOMESTIC ❑ FIRE ❑ IRRIGATION-C PROCESS ❑
MFG. kkil Ci.LS MODEL______0, SIZE `3�q SERIAL NO, G ZC/7Gb
LINE PRESSURE %S DATE INSTALLED LASTTEST
� ��� NE W K Existingn �/
LOCATION cr Y 19�� OW /iarc-0—
TEST DATE: f5 THE TECHNICIAN CERTIFIES TI riS ASSEMBLY RAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_.ASSE 5000
TESTPASS)d FAILED:0 TEST KIT /YI_"J=k pSl 84< RE-CALIBDATE:
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED: _ /?!A BY WHOM:
TIME TURNED OFF: �,(/� TIME TURNED ON: /V&4 X
CONTACT;
CERTx O CURT, EXPIRES: 4T/x9/Q—C1 —TESTER: 14-.T MIQ
ACCEPTED BY e
TESTER: Tune t $
Sig�amrc �—
Sigtuturt
Signing Otis report verifies Jut the isolcnon raves am in open position 1 cenifj under Pcnzlty of law Ituit I hove Persottnlly Performed dre test irv; NeI.ons and repairs whmined
and sbe tare alarm is furciianing. You agree to pay a finance clnrm or on dtis forn. All Win Pm=t!um uem performed in accoriaxe with the Ines: edition of the Cororade
1.5% per ",a mirimum of S5.00 whichever is tno•e or inwmrnc ,i,,,, —
Thirty (30) days p2sr due.
Cross-Connectmn S'auual. I Sclieve the submitted information is true, aecaratc. & complete. I tun aware
That there ure significant penalties for submitting false information in-lndinS the Possibility
or fines or imprisunmenr.
DWNFR
CA 176L999£OL6 uosuowiS eiuuoe dCV:90 LO 9l unf